community by community
O R G A N I Z E G O V E R N A N C E
INTRODUCTION
“Communityship needs to be strengthened in many organizations today.
This does not mean that we have to put it on a pedestal,
in place of leadership. It, too, can be overdone.
After all, witch hunts had their roots in community.
What we need is balance. We would do well, therefore, to see
both forces as working together in a socially responsible way
to get past the insularity that exists in many organizations. A healthy
society balances leadership, communityship, and citizenship.”
Henry Mintzberg (1939 – )
Henry Mintzberg is a professor of Management Studies at McGill University in Montreal. His “The Last Word” Commentary appeared in the July-August 2009 edition of the Harvard Business Review. The citation above is the last paragraph of the Commentary. Can there be any doubt? In one paragraph, does he not summarize the essential challenge for the reform of our nation’s healthcare industry?
In 1968, Senator Robert Kennedy spoke about a widespread social disturbance. It has now been worsening for the last 57 years and has destabilized all the strategies for healthcare reform that have been applied. Within the opening quotation from the “MINDLESS MENACE” Sub-Page of the PROSPECTUS Page, Senator Kennedy described his view of the pervasive violence occurring throughout our land. Although healthcare reform is the primary focus for NATIONAL HEALTH, the indirect motives for healthcare reform could also be its support for “A healthy society” and a related reduction in the “mindless menace of violence” that adversely affects the Family of each person within our nation’s neighborhoods, community by community.
This Global Task, ORGANIZE SYSTEMS, defines the leadership structure for the governance that would direct the affairs of NATIONAL HEALTH as it promotes “communityship and citizenship” for the reform of our nation’s healthcare. The capstone of each community’s Survival Commons, its healthcare, requires a revision of the paradigm shift that has occurred since 1960. This level of renewal must withstand many sources of turmoil, not just the pervasive violence in our neighborhoods. The degree of human goodness and strength to promote change still exists in every community. We must seek it out and remind our neighbors and their Extended Families about the fundamental strength that exists in every community to achieve Stable HEALTH For Each Resident Person.
The renewal of healthcare itself must be considered systematically, beginning with Primary Healthcare that is equitably available to and ecologically &culturally accessible by each resident person. Every community must begin this process in conjunction with a reduction of the social adversities affecting the Family of too many resident persons. The “Mindless Menace of Violence” should be on the list of social adversities requiring continuous prevention, mitigation, and amelioration.
LEADERSHIP FOR NATIONAL HEALTH
If NATIONAL HEALTH has an attribute open to honest differences of opinion, it is the process of selecting its initial and, subsequently, its permanent leadership to represent the spectrum of vested interests that will be required for its governance. Also, choosing the optimum size for a cluster of individuals to successfully govern an institution is not clearly understood. I have chosen nine. Given these uncertainties, the nine Members of the Board of Trustees of NATIONAL HEALTH would each represent, respectively, one of nine regional clusters of states. Each grouping of States would encompass an equal population of approximately 37,000,000 citizens. The resulting nine clusters of one or more states, including our nation’s protectorates, would coincide with regionally shared, social, and geographic characteristics. Each regional cluster would have its own Regional Council to assist the Board of Trustees in an advice and consent relationship. The Board of Trustees and its Regional Councils would share similar characteristics for the spectrum of their member selection attributes.
Eventually, the nine Regional Councils would each establish nine Sub-Councils and their nine District Coalitions, each formed to promote the Community HEALTH Forums among 4 million citizens. A total of 81 Regional District Coalitions would each promote a locally-driven formation of nine or more Community HEALTH Forums for the resident persons within their Regional Council Region. The functions of each Forum would be supported through mentoring and technical assistance by the Associates, i.e. staff employees, of their respective Regional Council. Each Forum would serve a community of between 100,000 and 600,000 (on average 400,000) resident persons, depending on geographic size and population density. Altogether, the nearly 810 Forums would each promote collective action as the basis for defining a Community HEALTH Plan, annually updated, to ensure that equitably available and ecologically & culturally accessible Primary Healthcare is offered to every resident person. Eventually, the nearly 810 Community HEALTH Plans would specify the development of HEALTH SECURITY certified Primary Healthcare throughout their community along with a description of its own Survival Commons, viz. augmented safety net. — 3 —
GETTING STARTED
The initial Members of the Board of Trustees and Regional Councils would be selected by a temporary, expedient process. This would involve a Governor from the state or group of states associated with each Regional Council achieving the lowest maternal mortality incidence. When all of the Sub-Regional Districts within a Region have been operational for two full years, the permanent process for selecting each of the Members for that Regional Council would begin. Once the affairs of NATIONAL HEALTH had stabilized, the Chairman of the Board of Trustees would recommend an applicant to become its President and Chief Executive Officer. The President/CEO would function as an ex officio Member of the Board of Trustees as defined by an Operational Statement approved by the Board of Trustees. Most importantly, the combined Membership of the Regional Councils, and Board of Trustees would achieve the requisite experience for the continuous acquisition of leadership skills throughout NATIONAL HEALTH.
This proposal requires the Board of Trustees for NATIONAL HEALTH to prepare an annual report for the President and Congress. The annual report would be the basis for proposing any new Congressional action that may be necessary to resolve any barriers to reform encountered by NATIONAL HEALTH. Optimally, these requests would not be controversial and would represent widely supported improvements in the reform process for our nation’s entire healthcare industry.
Locally connected leadership will be a special requirement for each Forum as they formulate their Community HEALTH Plan to mobilize the sources of assets for promoting the capabilities to offer equitably available Primary Healthcare to each resident person. This Plan would 1) eventually specify Primary Healthcare that has achieved HEALTH SECURITY certification and 2) avoid unintended but potentially divisive problems associated with provider panels, community anti-trust, intellectual property, neighborhood service areas, physician career commitments, or population shifts.
The basis for the Community HEALTH Plans may eventually require Congressional clarification given the risk of either inaction or anti-competitive activities. As the benefits of enhanced Primary Healthcare begin to mature, the nearly 810 Forums would eventually focus their Community HEALTH Plans on the other community HEALTH deficiencies. These would include a consideration of the current level of community-wide participation in local, regional, and national pre- and post-disaster preparedness. The vast majority of disasters are knowable, except for their exact location, strength, and timing. In one sense, the process of preparedness for knowably predictable disasters is the most important means to promote resilience for responding appropriately to disasters that are not substantially for-seeable, such as an Influenza pandemic.
Eventually, each of the Community HEALTH Forums’ annually revised Community HEALTH Plans would comprise three sections: the first Section which describes the adequacy of its Primary Healthcare, viz., 1) its availability as assured cooperatively by its local healthcare institutions, 2) its prevalence of HEALTH SECURITY Certification, and 3) its anticipated future augmentation needs; the second Section which would describe the community’s most prominent adversities that are amenable to the use of collective action strategies for their reduction or stabilization, such as 1) early childhood education, 2) adolescent health (suicide, obesity, STD), 3) pain management, or 4) homelessness; and Finally, the third Section which would describe the sustainable resilience of the community’s ability to prevent, mitigate, and ameliorate the effects of knowable disaster events including a written scenario for the steps in place to maintain this readiness, a COMMUNITY MASTER DISASTER PLAN.
A nationally sanctioned effort, community by community, to continuously maintain these Community HEALTH Plans should be the most important benefit within healthcare reform as it helps each community revitalize the importance of each person’s Family, its Family Culture, the Family’s Extended Family, and its Family’s close neighborhood. Finally, having each community and their adjacent communities compile mutually compatible Community HEALTH Plans may be its most valuable attribute for improving not only every community’s Survival Commons but also its contribution to improving our nation’s social cohesion. — 5 —
GOVERNANCE
The top two levels of governance would be established based on a plan described within a Congressional Charter and initiated by the President. A Sub-Page of the GOALS Page describes one model for selecting the initial MEMBERS of the Board of Trustees. The President, or a designee, would preside over the initial Meeting of the Board of Trustees at a location defined by the Congressional Charter. Presumably, the initial MEETING would 1) select its Officers and 2) establish the structure and content of the initial OPERATIONAL STATEMENTS including its General Operating Principles and an initial Strategic Projects Plan. A possible model for these two OPERATIONAL STATEMENTS can be found as Sub-Pages of the GOALS Page.
CONGRESSIONAL CHARTER PROVISIONS FOR THIS GLOBAL TASK
A. The Congressional Charter shall define the initial VISION and its PRINCIPLES for the affairs of NATIONAL HEALTH beginning with the initial Meeting of the Board of Trustees.
COMMENT For the first ten years, “Stable HEALTH For Each Resident Person“ would represent its VISION. And, its PRINCIPLES would be: Altruism, Trust, Cooperation, Reciprocity, and Excellence.
B. The Congressional Charter shall require NATIONAL HEALTH to achieve three GOALs within 10 years, establish and maintain four national projects to support healthcare reform, and implement a new strategy for arranging community-based collective action to guide its own Population HEALTH needs, neighborhood by neighborhood. The four national projects, the new strategy, and three GOALs shall be achieved within 10 years after the initial Meeting of the Board of Trustees.
1. The four national projects shall be defined as:
a. a PRIMARY HEALTHCARE BENEFITS PLAN that defines the minimum benefits to be covered by all financial sources for the reimbursement of health care provided to any resident person for their Basic Healthcare Needs including the options applicable for the augmented support of HEALTH SECURITY certified Primary Healthcare,
COMMENT This will likely take several years to finish. The use of multiple layers as a basis for recognizing regional and community institutional needs may be an important attribute of this PLAN to assure its local and regional acceptance. Promoting and improving the financial recognition of each community’s Primary Healthcare could be one of the most important contributions to the overall reform of our nation’s healthcare industry. A broad base of public support will be necessary for the successful completion of the PLAN. Furthermore, the legitimate concerns about change must be engaged responsively given the complex, institutional, and economic traditions involved.
b. a PRIMARY PHYSICIAN EDUCATION PLAN that describes the career-long educational stages necessary to ensure the equitable availability of Primary Physicians as required by the PRIMARY HEALTHCARE BENEFITS PLAN,
COMMENT As in “1.a.” above, an initially slow then rapidly evolving means to support and focus the efforts of our nation’s medical schools will be most important. The initial drafts of this PLAN should focus especially on defining a physician’s basic skill set required for Primary Healthcare. This preparedness should include, especially, the technical and emotional adaptability for managing the breadth and depth of daily uncertainty associated with a person’s Basic Healthcare Needs. This uncertainty is driven by the high level of chaotic disruption occurring concurrently to destabilize each resident person’s HEALTH that may be largely unknowable at the time of any health care encounter.
In addition, this PLAN would specify and implement a coordinated post-graduate medical education process for all Primary Physicians including their Nurse Practitioners and Physician Associates associated with a HEALTH SECURITY certified, Primary Healthcare clinic. Its coordination with the appropriate specialty certification Boards would be most important. A nationally sanctioned process for assuring a stable and adaptable curriculum regarding Stable HEALTH within the worldwide realms of its Resources, Knowledge, and Human Dignity will be necessary for the providers of enhanced Primary Healthcare within each community.
c. HEALTH SECURITY CERTIFICATION PLAN as a set of criteria necessary for any Primary Healthcare clinic to demonstrate proficiency as a basis to qualify for augmented financial support; AND
COMMENT The proficiency criteria should create a process that recognizes a clinic’s initial commitment to change as a basis for its immediately improved reimbursement. Subsequently, the annual level of increasing achievement required for continued Certification would be defined for a span of 3-5 years. As NATIONAL HEALTH matures, the initial “professional, non-economic buy-in” phase could be shortened to 1-2 years. The District Coalitions would monitor the Certification process, and NATIONAL HEALTH would use its own resources as may be required for this monitoring.
d. PRIMARY HEALTHCARE EFFICACY PLAN as the annually collated, State by State, payor distribution data for every Primary Healthcare clinic that is eventually stop-loss corrected, based on a national financial Risk-Management Strategy. — 7 —
COMMENT This PLAN may be the most difficult since it may take 3-5 years to become implemented to avoid any unintended problems, especially by the current healthcare payors. We would anticipate that the re-insurance carriers would separate responsibility for each Region (each, on average representing 37 million resident persons).
2. The new strategy shall be recognized for its ability to:
a. sponsor a locally driven, community-initiated assurance
that equitably available Primary Healthcare
is offered to each resident person of their community,
b. promote the use of collective action as a collaborative
community tradition to augment its
Survival Commons with an annually revised
Community HEALTH Plan in association
with its adjacent communities, and
c. promote a community-wide, global HEALTH
assessment tool that is reported monthly; AND
3. Three GOALs shall be achieved within ten years or
by its substantially steady improvement to:
a. reduce our nation’s annual health spending
to 13.0% or less of our nation’s gross
domestic product;
b. reduce our nation’s, annual maternal mortality rate
to 7.0 maternal deaths per 100,000 live births
or less, and
c. achieve state-by-state, ratification of the Congressional
Charter within 10 years after the First Meeting of
of the Board of Trustees.
COMMENT The final GOAL would be more likely if at least 30 States had ratified the Congressional Charter for NATIONAL HEALTH within the first 3-4 years following the initial Meeting of the Board of Trustees. The GOALs outcome requirement shall be the calendar year following ten full years of operational status beginning with the initial Meeting of the Board of Trustees.
C. The Board of Trustees shall have the sole authority and responsibility to carry out the affairs of NATIONAL HEALTH as defined by its Congressional Charter. The Board of Trustees shall:
1. establish its affairs according to the Congressional Charter;
COMMENT A Sub-Page of the GOALs Page describes one alternative for inclusion within the Congressional Charter as a basis to appoint the Membership for the Initial MEETING of the Board of Trustees.
2. have a non-voting Member selected within three years by the
Chairman and approved by the Board of Trustees
for a term of 5 years as the President and
Chief Executive Officer of NATIONAL HEALTH
with eligibility for an additional 5 years
for a maximal appointment of fifteen years;
COMMENT The initial Chairman may be a logical choice for this responsibility during the first 3 years. The oversight role of the President and Congress should be defined within the Congressional Charter for selecting this person:
3. have 9 Members appointed temporarily that are replaced
according to a permanent selection process defined
in the Congressional Charter;
4. have 9 Members appointed permanently
beginning 3 years after the initial MEETING
to include at least 5 overlapping Members:
a. one Member selected by the Members
of each Regional Council and approved
by the Board of Trustees for equally overlapping
terms of 9 years from their respective Region,
b. select a Chairman from the current Members,
having at least four years remaining
as a Member, and
c. select a Vice-Chairman, who has at least two more years
remaining as a Member, by a vote of the Members
every two years beginning the third year
after the initial MEETING;
5. establish nine Regional Councils according to the following
groupings of States: — 9 —
COMMENT For the set of State clusters for NATIONAL HEALTH, I have taken the actual year of Statehood among the States of each respective Regional grouping to determine an average. A rank ordering of these Regions recognizes the earliest versus the later, year of Statehood groupings of States. The protectorates are not included in the average. The State groupings represent citizen populations that average very close to 37 million citizens. See the initial GOVERNANCE Sub-Page for the actual data.
Region 1 Central East – 1787: Pennsylvania (1787),
New Jersey (1787), Maryland (1787), Delaware (1788),
District of Columbia, Puerto Rico, U.S. Virgin Islands;
Region 2 North East – 1794: Massachusetts (1787),
New York (1788), Connecticut (1788),
New Hampshire (1788), Rhode Island (1790),
Vermont (1791), Maine (1820);
Region 3 South East – 1804: Georgia (1788),
Virginia (1788), South Carolina (1788),
North Carolina (1789), West Virginia (1863);
Region 4 Central – 1806: Kentucky (1792),
Tennessee (1796), Ohio (1803),
Indiana (1816), Missouri (1821);
Region 5 South Central – 1826: Louisiana (1812),
Mississippi (1817), Alabama (1819),
Arkansas (1836), Florida (1845);
Region 6 North Central – 1841: Illinois (1818),
Michigan (1837), Iowa (1846),
Wisconsin (1848), Minnesota (1858);
Region 7 Central West – 1850: California (1850);
Region 8 South West – 1898: Texas (1845),
Oklahoma (1907), Arizona (1912),
New Mexico (1912); and
Region 9 North West – 1908: Oregon (1859),
Kansas (1861), Nevada (1864),
Nebraska (1867), Colorado (1876), Montana (1880),
North Dakota (1989), South Dakota (1889),
Washington (1889), Wyoming (1890),
Idaho (1890), Utah (1896), Alaska (1959),
Hawaii (1959), the residents of Samoa and Guam;
6. having a requirement for each Member of the Board of Trustees
that reflects their expertise of applicable experience
for at least 25 years:
a. five Members as medical doctors with three
of these Members as Primary Physicians,
b. one Member as an independent mental health practitioner
who is not a medical doctor,
c. one Member as an epidemiologist
who is not a medical doctor, and
d. two other Members representing sustainably resilient
leadership, especially with professional skills
associated with ethics or behavioral economics
who are not medical doctors;
7. Establish an Operational Statement for the affairs
of the Regional Councils whose Members
are selected from Nominees recommended
by a District Coalition to the Governor
of a Region’s State with the best Primary Healthcare
equitable availability;
COMMENT: The Membership requirements for each Regional Council would be similar to those of the Board of Trustees.
8. Establish an Operational Statement for the affairs
of each District Community limiting their responsibilities
to a cluster, on average, of 3-5 million resident persons
residing within the State or States served by their
respective Regional Council:
a. A District Community may have a portion
of its resident persons living in two States
as long as the two States belong
to the same Regional Council,
b. The Members shall be appointed for equally
overlapping terms of nine years by the
applicable Regional Council
with Members to include:
i. three Primary Physicians,
ii. one BSN/Registered Nurse from a HHS
sponsored Community Health Center,
iii. one from a community public health
department and have at least
a Master’s Degree,
preferably in Public Health,
iv. one from a medical school faculty as a medical
doctor with leadership responsibility
for curriculum development associated
with medical student education,
v. three from the community that may be selected
from those counties of a District Community
associated with three levels
of population density, and
vi. one non-voting, full-time, administrative
support person [This person might assume
the role of the Vice-Chairman. The person
would be appointed by the Chairman
of the respective Regional Council
for a five-year term and be eligible
for an additional 5-year reappointment;
AND
c. Each District Community, under the authority of their
respective Regional Council, will establish
an Operational Statement for the affairs of their
Community HEALTH Forums. — 11 —
COMMENT Each Community HEALTH Forum would 1) serve contiguous geographic areas within a District Community’s boundary, 2) generally respect county borders, and 3) be responsible initially for promoting the equitably available Primary Healthcare needs of between 100,000 to 600,000 citizens.
9. Establish an Operational Statement for notifying the
Board of Trustees Chairman in case of a vacancy
for any Member’s appointment. A vacancy
shall be declared as a result of a majority decision
by the Chairman, Vice-Chairman, and
the current Member with the longest length
of appointment to the related Board of Trustees,
Regional Council, or District Coalition; AND
10. Locate the home office for the Board of Trustees,
Regional Council, District Coalition, or
Community HEALTH Forum based on the
same criteria and establish the initial
home office for NATIONAL HEALTH
at St. Louis, Missouri:
a. equitable travel time by each respective resident
citizen nationally, regionally, district, and
community,
b. equitable travel distance to a medical school or
school of public health, and
c. equitable travel distance to a state’s legislature.
COMMENT The Board of Trustees shall establish an Operational Statement for the home office locations and periodically revise the Operational Statement at least every ten years. Our nation’s population center in 2010 was located southwest of St. Louis about half-way between St. Louis and Springfield and close to the city of Plato, Missouri. ]
D. While maintaining regular consultation with the Regional Councils, the Board of Trustees shall manage the affairs of NATIONAL HEALTH based on an annually revised Strategic Development Plan approved by the Board of Trustees. The advice and consent relationship between the Board of Trustees and the Regional Councils shall require an official review of any Policy or Procedure for the first time and subsequently, for any revision, if the Board of Trustees retained the final Approval Authority of the previously approved Operational Statement.
COMMENT A preliminary draft for the initial Strategic Projects Plan can be found as a Sub-Page of the GOALs Page.
E. After consultation with each Regional Council, the Board of Trustees at any time may authorize its Chairman to submit a request to the President for a Congressional revision of existing Federal Regulations or laws for the purpose of improving the ability of NATIONAL HEALTH to implement its Congressional Charter. This authority may include proposals for a change in the Congressional Charter for NATIONAL HEALTH excluding any authority to participate in the direct financial reimbursement or any other form of direct economic support for the healthcare of a resident person, excluding any health insurance plan for Associates employed by NATIONAL HEALTH.
F. All public or private institutions interacting with NATIONAL HEALTH shall recognize a single definition for Primary Healthcare as may be defined by NATIONAL HEALTH and for any other related definitions to clarify its meaning.
COMMENT A preliminary definition of Primary Healthcare may be found on the GLOSSARY for HEALTHCARE Sub-Page of the APPENDIX Page.
G. The Board of Trustees shall authorize the Chairman to propose an Operational Statement for the structure and content within the Policies and Procedures of NATIONAL HEALTH. These Operational Statements shall use polycentric and derivative concepts as a basis for governance. The Board of Trustees shall retain ultimate responsibility for the affairs of NATIONAL HEALTH as defined by the Congressional Charter authorization. The Board of Trustees may delegate certain of these responsibilities to its Chairman, or to the Regional Councils. — 13 —
COMMENT A sample Operational Statement for the GENERAL OPERATING PRINCIPLES may be found on a Sub-Page of the GOALS Page.
H. Decisions of the Board of Trustees, Regional Councils, and District Coalitions shall require a quorum of 5 Members. Any Meeting of a Community HEALTH Forum may not occur without the presence of 5 Advocates, with or without a previously identified selection designation.
I. Three years prior to restarting the Nine Region sequence for appointing Members to the Board of Trustees, the Chairman shall initiate a reconsideration of criteria for assessing the level of healthcare accessibility for each State. Initially, it shall be its maternal mortality ratio as measured as a running 5-year mean.
COMMENT As of 2016, the data most recently available was for the years 2005 through 2014. Conceivably, this measurement tool might eventually represent the weighted average of several statistics, as in motor vehicle accident mortality, poverty level, as well as maternal mortality.
J. The deliberations of the Board of Trustees, Regional Councils, and District Coalitions shall follow “Roberts’s Rules of Order, Newly Revised” except when the Chairman declares a temporary Open Collaboration form of deliberation. Each Community HEALTH Forum shall follow an Open Collaboration form of deliberation.
COMMENT No Forum would have the authority or responsibility to directly implement any plan. Their role will reflect only an effort to attain consensus and to monitor the shared responsibility among the principal stakeholders within their own community.
K. The Board of Trustees shall establish an Operational Statement for Special Meetings applicable to itself, the Regional Councils, and the District Councils. This Operational Statement shall also provide recognition of the applicable State laws for
1. the Notice and Limited Agenda Subjects for any closed
Special Meeting and
2. any requirements or unique appointments for independent
observers.
L. The Board of Trustees shall initiate a Planning Task Force to assess the future evolution of NATIONAL HEALTH starting five years after the initial Meeting of the Board of Trustees and every ten years thereafter. Any possible changes would require a proposal to the President and approved by Congress for the Congressional Charter of NATIONAL HEALTH.